Graft Failure Rates in Bone–Patellar Tendon–Bone, Hamstring, and Quadriceps Tendon Autografts in Patients Younger Than 25 Years: A Meta-analysis

Background: Anterior cruciate ligament reconstruction (ACLR) is being increasingly performed in part because of higher injury rates among young athletes (≤25 years). High allograft failure rates support the use of autograft for ACLR in young patients. However, data examining the failure rates of the different autografts used in this population are lacking. Purpose: The purpose of this study was to compare graft failure rates among bone–patellar tendon–bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT) autografts in patients ≤25 years old. The secondary aim was to stratify graft failure by potential modifiers, including sex, mean follow-up, time to graft rupture, and concomitant meniscal surgery. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: Studies were included that reported anterior cruciate ligament graft (BPTB, HT, QT) reinjury rates in patients ≤25 years old with a minimum 24 months of follow-up. Studies were excluded if they examined revision ACLR, allograft ACLR, allograft augmentation ACLR, or concomitant lateral extra-articular tenodesis or if they failed to report reinjury rates by graft type and young age (≤25 years). Results: This review included 46 studies comprising 10,624 patients (HT: n = 6090, 47.0% female, 54.5-month mean follow-up; BPTB: n = 3990, 63.0% female, 63.6-month mean follow-up; QT: n = 544, 40.3% female, 41.6-month mean follow-up). HT exhibited the highest failure rate at 11.1% (95% CI, 8.8%-13.9%). Failure rates for BPTB and QT were 5.1% (95% CI, 3.5%-7.2%) and 2.5% (95% CI, 0.5%-11.2%), respectively. HT had a significantly higher failure rate than BPTB ( Q = 13.1; P < .001). There were no significant differences in failure rates between HT and QT ( Q = 3.7; P = .06) or between BPTB and QT ( Q = 0.8; P = .4). Males and females had a similar risk of graft failure regardless of graft type. Conclusion: The results of this meta-analysis suggest that HT grafts are not the optimal choice for young patients undergoing ACLR. Instead, these patients should consider BPTB to reduce the risk of graft failure. Further research including randomized controlled trials with larger sample sizes are required to determine how QT grafts compare with BPTB grafts in this population.